"Long Term Care Facility - Self-reported Incident Form" - Kentucky

Long Term Care Facility - Self-reported Incident Form is a legal document that was released by the Kentucky Secretary of State - a government authority operating within Kentucky.

Form Details:

  • Released on October 1, 2017;
  • The latest edition currently provided by the Kentucky Secretary of State;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Kentucky Secretary of State.

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Kentucky Cabinet for Health and Family Services
Office of Inspector General – Division of Health Care
Long Term Care Facility – Self-Reported Incident Form
Initial Report
5 Day Follow up/Final Report
Combined Incident Report/Final Report
Please complete Parts A & B for initial notifications. Include Part C for 5 day Follow up/Final Reports.
Part A
Name of Facility ____________________________________________________
Address ________________________________________________________________________________
Street
City
State
Zip
Incident Date _________________ Incident Location ____________________________________________
Resident(s)/Client(s) Involved _______________________________________________________________
Staff Involved ___________________________________________________________________________
Required Incident Reports
Optional Incident Reports
Notifications(Check all that apply)
Fire
Communicable Disease
Physician
Missing Resident/Elopement
Outbreak of Infectious Disease
Family/Guardian
Injuries of Unknown Source
Storm Damage
Resident’s Legal Representative
Allegations of Neglect
Utility Failure (more than 4 hours)
DCBS
Exploitation/Misappropriation of
Care and Treatment Concerns
Local Law enforcement
Property
Incident Involving Life Safety Code
Appropriate Licensing Board
Allegations of Abuse/Mistreatment
Death Other than by Natural Causes
Attorney General
Other _______________________
Serious Bodily Injury
Ombudsman
Physical Abuse
Other ____________________
Sexual Abuse
Mental Abuse
Verbal Abuse
Seclusion
Part B
Description of Incident. Please include injuries sustained as well as measures taken to protect the
(Limit of 500 characters attach additional pages as necessary)
resident(s) during investigation.
Please include relevant resident history
(i.e. cognitive status, fall risk assessment, relevant care plan
(Limit of 500 characters attach additional pages as necessary)
instructions prior to this incident, etc.)
Part C
For 5-working day/final reports, please include a summary of the investigation
(include investigative
and corrective measures implemented to prevent recurrence.
actions, findings and causative factors)
(Limit of 500 characters attach additional pages as necessary)
_____________________________
____________________________________
________
Reporting Party (type or print clearly)
Date
Reporting Party’s Contact Number
______________________________
Reporting Party’s email Address
10.17
Page ___ of ___
Kentucky Cabinet for Health and Family Services
Office of Inspector General – Division of Health Care
Long Term Care Facility – Self-Reported Incident Form
Initial Report
5 Day Follow up/Final Report
Combined Incident Report/Final Report
Please complete Parts A & B for initial notifications. Include Part C for 5 day Follow up/Final Reports.
Part A
Name of Facility ____________________________________________________
Address ________________________________________________________________________________
Street
City
State
Zip
Incident Date _________________ Incident Location ____________________________________________
Resident(s)/Client(s) Involved _______________________________________________________________
Staff Involved ___________________________________________________________________________
Required Incident Reports
Optional Incident Reports
Notifications(Check all that apply)
Fire
Communicable Disease
Physician
Missing Resident/Elopement
Outbreak of Infectious Disease
Family/Guardian
Injuries of Unknown Source
Storm Damage
Resident’s Legal Representative
Allegations of Neglect
Utility Failure (more than 4 hours)
DCBS
Exploitation/Misappropriation of
Care and Treatment Concerns
Local Law enforcement
Property
Incident Involving Life Safety Code
Appropriate Licensing Board
Allegations of Abuse/Mistreatment
Death Other than by Natural Causes
Attorney General
Other _______________________
Serious Bodily Injury
Ombudsman
Physical Abuse
Other ____________________
Sexual Abuse
Mental Abuse
Verbal Abuse
Seclusion
Part B
Description of Incident. Please include injuries sustained as well as measures taken to protect the
(Limit of 500 characters attach additional pages as necessary)
resident(s) during investigation.
Please include relevant resident history
(i.e. cognitive status, fall risk assessment, relevant care plan
(Limit of 500 characters attach additional pages as necessary)
instructions prior to this incident, etc.)
Part C
For 5-working day/final reports, please include a summary of the investigation
(include investigative
and corrective measures implemented to prevent recurrence.
actions, findings and causative factors)
(Limit of 500 characters attach additional pages as necessary)
_____________________________
____________________________________
________
Reporting Party (type or print clearly)
Date
Reporting Party’s Contact Number
______________________________
Reporting Party’s email Address
10.17
Page ___ of ___